Anticipated Impacts on Veteran's Healthcare This study will provide a comprehensive national assessment of the use of VA and non-VA health services, VA-financed costs, and quality of care for all VA enrollees who are dually enrolled in a Medicare Advantage (MA) plan. Our preliminary findings indicate that 11% of all VA users in CY2009 were simultaneously enrolled in an MA plan and that the VA spent $3.2 billion (approximately 10% of its operating budget) on health services for this population. Therefore, the coordination of financing and service delivery across these two managed care systems is of vital interest to VA and other federal policymakers. The goal of this project is to inform federal policy regarding the financing and delivery of health care for persons who are dually enrolled in the VA and MA. Project Background In the United States, eligible adults may choose to enroll simultaneously in two distinct managed care systems: the MA program administered by the Centers for Medicare and Medicaid Services and the VA Healthcare System, administered by the Veterans Health Administration. Although the VA may collect reimbursements for care provided to VA users enrolled in private health plans, federal law prohibits the VA from collecting any reimbursements from Medicare-financed health plans. Dual enrollment may produce redundant federal payments and fragmentation of care for enrollees with complex chronic medical conditions. Few studies have quantified the clinical and economic consequences of dual enrollment in VA and MA. Project Objectives Our primary objectives are: (1) to assess the utilization and VA-financed costs of health care services for VA health care system users who are simultaneously enrolled in a Medicare Advantage plan; (2) to compare the quality of diabetes, cardiovascular, and cancer screening care among the following three groups of veterans who are dually enrolled in VA and MA: veterans who exclusively receive care in the VA, veterans who receive care in both VA and MA, and veterans who exclusively receive care in MA; (3) to understand the effect of fragmented financing on the quality of care among dual enrollees in VA and Medicare Advantage. Project Methods We will merge 13 national VA and Medicare clinical and administrative datasets from 2004 through 2013 to derive the population of all VA enrollees who were simultaneously enrolled in a Medicare Advantage plan. For this cohort, we will assess the distribution of ambulatory and acute inpatient care in the VA and Medicare Advantage, the total costs of VA-financed care using average-cost methods, and the effect of fragmented financing on the quality of care for dually enrolled veterans using both instrumental variable and propensity-score approaches.